Download Public Health 101

Public Health 101
2009 NACCHO/APC Road Show
Public Health 101 –
An Introduction for
Public Health Stakeholders
Presented by
Southwest Center for
Advanced Public Health Practice
Tarrant County Public Health, TX
2009
Course Objectives
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Identify the basic roles and responsibilities of a local
public health agency
Discuss the importance of collaboration between
public health and its stakeholders in the event of an
emergency
Provide examples of events that are within the scope
of public health preparedness
Explain and demonstrate how public health utilizes
ICS during emergencies
Describe several of the main steps in an outbreak
investigation
List scenarios where public health and first responders
are most likely to interface
Course Outline
I.
Introduction to Public Health
II. Public Health Preparedness
III. Incident Command System (ICS)
IV. Public Health Response to Emergencies
V. Strategic National Stockpile (SNS)
VI. Introduction to Epidemiology
VII. Isolation and Quarantine
VIII.Case Study: Avian Influenza Outbreak
What is Health?
• Health is a state of complete
physical, mental and social wellbeing and not merely the
absence of disease or infirmity.
Public Health vs. Medicine
Patient
Public Health
Medicine
Entire Populations
Individuals
Intervent Assess, Policy
Development &
ion
Assurance
Process System
Management
Outcome Healthy
Community
Medical
Treatment
Patient
Management
Healing
Public Health Objectives
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Prevent epidemics and the spread of disease
Protect against environmental hazards
Prevent injuries
Promote and encourage healthy behaviors
Respond to disasters and assist communities
in recovery
Assure the quality and accessibility of health
services
… derived from American Public Health Association, Ten
Essential Services
Typical Menu of Public Health Services
• Personal Health Services (clinical services)
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Immunizations
STD/HIV testing and counseling
Chronic disease counseling
Tuberculosis services
Family planning and maternal & child health
services
– Travel health services
BUT…providing direct clinical services is only one
part of the mission of a local health department
Population Based
Public Health Services
• Environmental Health
• Infectious Disease Control and
Investigation
• Laboratory Services
• Health Education Services
The Public Health
System
Federal Agencies
State Agencies
Local Agencies
Public Health’s Many Partners
Police
EMS
Home Health
MCOs Churches
Corrections
Health
Department
Community
Centers
Parks
Schools
Doctors
Hospitals
Philanthropist
Civic Groups
CHCs
Elected
Mass Transit
Officials Nursing
Homes
Environmental
Health
Fire
Laboratory
Facilities
Drug
Treatment
Tribal Health
Economic
Mental
Employers
Development
Health
Which level of government is
responsible for protecting public
health?
• 10th Amendment to the U.S.
Constitution:
– All powers not delegated to the
Federal government shall be reserved
for the state governments
• States are responsible for
protecting public health
What is Public Health
Preparedness?
“Plans,
procedures,
policies,
training,
and equipment
necessary to
maximize the
ability to prevent,
respond and
recover from
major events.”
(HSPD-21)
Public Health Preparedness
Builds Infrastructure for:
Public Health Emergencies
Bioterrorism, pandemics
Everyday health threats
Infectious & foodborne
diseases
Preparedness and Bioterrorism
What is
bioterrorism???
-- The use of...
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Bacteria
Viruses
Parasites
Their by-products
…in a terrorist act.
Preparedness and Bioterrorism
• Possible agents of
bioterrorism
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Anthrax
Smallpox
Plague
Botulism
Preparedness and Bioterrorism
• What might an attack of bioterrorism
look like?
– Not necessarily explosions or plumes of
smoke
– May not be readily apparent and detectable
– Sick people arrive at hospitals or doctors’
offices
– Delayed recognition and diagnosis
– Population panic
Roles in Preparedness
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Planning
Coordination/Collaboration
Training and Exercise
Response
Evaluation and Corrective
Action
Collaboration is critical to success!
Roles in Preparedness
Situation Examples:
– Outbreaks from
contaminated food
or water, infectious
diseases, etc.
– Natural disasters:
hurricanes, floods,
fires
Roles in Preparedness
• Examples of public
health job roles:
– Health threats
investigator
– Public
service/media
– Post-event tracking
– Environmental
investigators
Incident Command System
• Allows a more
effective, efficient
response to
emergencies
• Examples:
– HazMat incidents
– Terrorist incidents
– Natural disasters
– Incidents
involving multiple
casualties
Incident Command & Public Health
• In the event of a public
health emergency the
public health director will
interact with the local EOC
or incident command post.
• The public health
Department of Operations
Center (DOC) may be
activated to facilitate
tactical communications.
Public Health Responding to
Emergencies
• In what type events would you
expect Public Health to assume
lead role for providing health and
medical services ?
Public Health Preparedness
Summary
• Build public health infrastructure to
respond to threats from:
– Bioterrorism
– Natural disasters & disease outbreaks
• Requires collaboration between agencies:
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Planning
Training & exercises
Response
Communication
Management of resources
Strategic National
Stockpile
Strategic National Stockpile
(SNS)
• A national stockpile available in the event
of a major terrorist attack against the
civilian US population
• National repository consisting of:
– Pharmaceuticals (i.e., antibiotics and vaccines)
– Antidotes and antitoxins
– Medical and surgical supplies
Strategic National Stockpile
• SNS is a federal asset deployed
locally after a major disaster
– The governor of the affected state
requests deployment of SNS from:
Strategic National Stockpile
• Delivered within 12
hours of federal
decision to deploy
SNS assets
– 12-hour “Push Package”
– Push packages are
warehoused in
strategically- positioned
locations around the US
Local Response to
Strategic National Stockpile
SNS deployment is a large-scale event
requiring adequate:
•Security
Pre–determined Points of Distribution
•Crowd control
•Traffic control
Local Response to
Strategic National Stockpile
• Essential that First Responders and
others in contact with exposed civilians
are the first to be medicated
Local Response to
Strategic National Stockpile
• Must prepare to dispense medicine to a
large number of people in a relatively
short time span
Local Response to
Strategic National Stockpile
• Expect to work with Public Health:
•Work collaboratively
•Implement emergency response
according to prior planning
•Have conducted prior training and
exercises
•Interagency Cross-Training
Epidemiology
What is Epidemiology?
Study of the spread and causes of
diseases or events in specified
populations, and the control of health
problems.
Epidemiology concerned with
OUTBREAKS
• An adverse health event involving
an unusual increase in cases among
a certain population of individuals,
within a certain period of time, in a
certain location
Areas of Epidemiology
• Infectious diseases
• Environmental
• Behavioral
• Forensic
• Disaster
Key Elements in Epidemiology
• Person
• Place
• Time
Epidemiology Study Examples
(risk or exposure
outcome)
• Smoking (exposure) increases
the risk of developing Lung
Cancer (outcome)
Epidemiology Study Examples
(risk or exposure
outcome)
• Eating undercooked hamburger
(exposure) increases the risk of
infection with the bacteria E. coli
(outcome).
Epidemiology Study Examples
(risk or exposure
outcome)
• Getting a flu shot (exposure)
decreases the risk of
becoming ill with the flu
(outcome).
Simplified Steps in an
Outbreak Investigation
1. Confirm outbreak and verify
diagnosis
2. Perform field work and complete
study
3. Implement control and prevention
measures
4. Communicate findings
Disease Reporting: Notifiable Diseases
• Healthcare providers are required by law
to report patients with certain diseases
and conditions:
– Report immediately (in most states)
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Potential BT agents (anthrax, smallpox, plague)
Botulism (foodborne)
Viral hemorrhagic fever, including Ebola
Other selected contagious serious diseases that
may affect children and immune compromised or
un-protected victims
Isolation and Quarantine
Protocol
History of
Quarantine
• In the fourteenth century, to protect cities from
plague epidemics, ships arriving in Venice from
infected ports had to sit at anchor for forty days
before landing.
• “Quarantine” is derived from the Latin word
quaresma, meaning forty.
Definitions:
Isolation:
• The separation of someone who’s
infected or contaminated from
others so that the infection or
contamination is not spread
Quarantine
• Limitation of freedom of movement
of a well person who’s been
exposed to an infectious agent
What Does it Mean to be
Isolated or Quarantined?
• No contact with any new people
• Can not leave home or place of
containment
• For evaluation and verification purposes
patient needs to check in with
Public Health every day
What is Voluntary
Compliance?
•Voluntary compliance with isolation,
quarantine or other control measures
means a patient cooperates and
complies with Public Health’s
instructions to comply with the
recommended control measures in
order to prevent the spread of
disease.
What is Involuntary
Detention?
• This is what Public Health will pursue if
an individual does not voluntarily
comply with an ordered control
measure.
To What or Who Can
“Control Measures” be Imposed?
• Person (s)
• Groups (5 or more individuals)
• Area (city block, ZIP code, county)
– Buildings (hospital, hotel, business)*
– Common Carrier (plane, bus, train)*
Who Can Enforce these
Rules?
• Local law enforcement must
enforce an order issued by local
health authority.
Questions?
Case study: Influenza Outbreak
Background on avian influenza:
Strains of influenza that infect birds
Circulate among wild water birds
Bird-to-bird transmission via:
Fecal material
Saliva
Nasal & respiratory secretions
A Pandemic
is a World-Wide Epidemic
A new bacteria or virus that can
infect humans
Nearly all people have no
immunity to the new organism
High mortality rate
Easily spread from person to
person.
Background – Avian Influenza
– Varying severity and
infectiousness among birds
– The highly pathological avian
influenza (HPAI) is the virus
that is a pandemic among
migrating water fowl.
– Potential to combine with
human flu virus to produce a
“new” influenza transmissible to
humans that could be lethal.
Viral reassortment
• Mixing of viral genes
from two different
animal species
simultaneously
Example:
Human infected with
human and avian
influenza virus at the
same time
Influenza Virus Transmission
Influenza viruses have
the potential to
mutate rapidly and
gain the ability to
spread from:
• Birds to farm
animals (i.e., pigs)
• Animals to
humans
• Birds to humans
(directly)
Avian Influenza Virus
Transmission Concerns
1. Strain efficiently
transmitted
between birds
and humans
2. Strain efficiently
transmitted from
human to human
Influenza Outbreak Scenario
Scenario:
A highly infectious
form of avian
influenza begins
to circulate among
poultry at a farm
in Hong Kong.
Influenza Outbreak
• The owner of the farm
also has several pig
pens
• The pig pens are
located right next to
the bird cages
• The feed troughs for
both the pigs and
poultry are often
interchanged
Influenza Outbreak
• The avian flu virus
mutates and infects
several of the pigs.
• The virus mutates
again and is
transmitted from one
of the pigs to the farm
owner.
Bird →Pig →Human
Influenza Outbreak
• The farm owner
wakes up one
morning suffering
from:
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Fever
Sore throat
Coughing
Muscle aches
Influenza Outbreak
• In the afternoon, he
travels into the
crowded capital city to
sell his poultry at the
local market.
• He is in extremely
close contact with
customers for several
hours.
Influenza Outbreak
• A couple days later,
several of the
customers from
the market begin
to show symptoms
of flu-like illness:
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Coughing
Fever
Sore throat
Muscle aches
Influenza Outbreak
• Several of them
work in the kitchen
of a nearby hotel
restaurant
• The restaurant is
popular among
Americans on
business trips in
Hong Kong.
Influenza Outbreak
• A Tarrant County
resident traveling in
Hong Kong on a
business trip stays at
the hotel.
• He eats at the hotel
restaurant on an
evening in which one
of the infected
workers is preparing
food.
Influenza Outbreak
• The businessman is
infected with flu.
• Within a few days of
eating at the
restaurant, he exhibits
flu-like symptoms.
• The following day, he
flies home to DFW.
Influenza Outbreak
Influenza Outbreak
Within days after the
resident returns
home, local hospitals
see an increase in
patients presenting
with:
• coughing
• fever
• muscle aches
Influenza Outbreak
• Local physicians
report similar trends
in symptoms seen in
recent days in their
private practices.
Influenza Outbreak
• Over the next couple
days, several EMS
workers who’ve been
transporting ill
patients, call in sick to
work complaining of
flu-like symptoms.
• The work-force loses
capacity because so
many employees have
fallen ill.
Question 1
• What factors might be contributing to
EMS staff contracting influenza?
(Hint: prior influenza vaccination likely
would NOT be effective in preventing
infection from an avian flu virus)
Answer
• Staff were not taking appropriate
protective measures around infected
persons:
– Not regularly washing hands after contact
with sick individuals
– Failing to wear personal protective equipment
(masks and gloves)
– Failing to disinfect contaminated surfaces and
medical equipment after transporting patients
Question 2
• Could this influenza outbreak have
been prevented completely?
Answer
Highly unlikely :
– Population has little to
no immunity against a
new avian flu virus
strain
– Prior influenza
vaccination not
protective against avian
flu virus strain
– Minimum of 6 months
needed to develop a
new flu vaccine
However . . .
Question 3
• Could the magnitude of this outbreak
have been reduced?
Answer
Yes – it is likely the
magnitude of the
outbreak could have
been reduced by:
– Earlier attention to health alerts
– Regular hand washing after
contact with patients
– Wearing personal protective
equipment (masks, gloves,
gowns)
– Regularly disinfecting surfaces
and medical equipment
Question 4
• Would a quarantine be required?
Answer
• Yes - general quarantine precautions
would apply:
– An infected patient (with SARS, Avian, TB or
even H1N1) on an international flight CAN
be detained at the airport terminal
– CDC, airport and local public health
authorities can request flight manifests and
have passengers undergo medical screening
for their safety
– A non-compliant patient can be arrested
and sent to forced isolation or quarantine
Question 5
• Why would a non-compliant person
be arrested and sent to forced
isolation or quarantine?
Answer
• So the non-compliant patient does
not endanger the public or
themselves.
Influenza Outbreak Summary
• BE RESPONSIBLE!!
• It is especially important . . .
– Wash hands or use sanitizers regularly
– Practice good respiratory hygiene and
cough etiquette
– Don’t come to work when you are sick
– Get a flu shot each year
Influenza Outbreak
Disclaimer
Disclaimer:
 Currently no sustainable human-tohuman transmission of bird flu has
been reported
 However, cases of human-to-human
transmission continue to occur and the
virus continues to mutate
Therefore, we must be prepared for
this possibility
Conclusions and Questions
Credits
This course was made possible through the efforts of public health
and EMS staff from Dekalb County, GA and Tarrant County, TX:
Darren Collins*, MPH, Dekalb
Jason Craw* Dekalb
* - Originating authors
Bill Stephens, MS, Tarrant
Kay Sanyal-Mukherji, MPH, Tarrant
Micky Moerbe, MPH, Tarrant
Diana Cervantes, MS, Tarrant
Jennifer Dowdy, MPH, Tarrant
Mark Fulmer, MS, Tarrant
Terry Lafon, RN, Tarrant
Teresa Bates, LVN, Tarrant
Donald Fisher, MS, Tarrant
Reviewed by Dr. Elvin Adams, MD, FACEP, Health Authority, Tarrant
This training was produced by the Southwest Center for Advanced Public Health Practice (Center) at
Tarrant County Public Health, and was supported by Cooperative Agreement Number U50/CCU302718
from the Centers for Disease Control and Prevention (CDC) to the National Association of County and
City Health Officials (NACCHO). Its contents are solely the responsibility of Center and do not
necessarily represent the official views of CDC or NACCHO